Baseball and Hope

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Baseball and Hope

 

It was spring and Baseball had started. I went to the Arizona Diamondbacks home opener and found a gentle renewal of hope. Even though they lost, blowing a middle inning lead in the sixth, the rhythms and optimism of the game, especially the first game of the season, were invigorating.

For me, spring baseball has always been about hopeful expectations. Your team may have ended the season in the cellar, but each new season brings new hope. Maybe this year we’ll win the division. Maybe we’ll top .500 for the season. Anything seems possible.

I’ve had a tough couple of months lately at work. I worked harder for less income last year and the winds of change coming out of the ACA and the insurance industry don’t look friendly to the individual practitioner. We’ve had a run of tragic and difficult cases on the trauma service and I’ve lost some of my usual objectivity in the face of it. Things are changing in the hospitals were I work, and not for the better, but I can’t seem to do anything to reverse or stop it.

I really needed a night out, and Opening Day was perfect. The grass was green, the uniforms were crisp and white, the beer was cold and the dogs were hot and all seemed right with the world. At least for a few hours, there was hope. Batter up!

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Handling Risk

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Handling Risk

 

“For sheer unadulterated ego, no one is a match for fighter pilots. Except maybe surgeons. Surgeons are in a class by themselves.” Tom Wolfe, The Right Stuff

The popular perception of surgeons is similar to the popular perception of fighter pilots. Arrogant self-confidence, disdain for thoughtful planning and reflection, quick to take action – ‘shoot first, ask questions later’, reckless courage in the face of danger, all are considered typical of the personality type.

Like all stereotypes, there is an element of truth behind the perception. Both surgeons and fighter pilots do jobs that are inherently unnatural. There is nothing ‘natural’ about flying a machine at speeds faster than the sound made by its own engines. There is nothing ‘natural’ about cutting into another human being’s body and rearranging its anatomy.

Performing at a high level in these arenas requires a special kind of confidence in one’s own ability and judgment, a confidence that is often mistaken for arrogance. The willingness to take action in the face of uncertainty, to make irrevocable decisions based on incomplete information, is often mistaken for recklessness. Acceptance of personal responsibility for the consequences of those actions may be mistaken for a disdain for cooperative effort.

I know several former fighter pilots. They’d all make good surgeons. And contrary to the popular perception, they are some of the most conservative and risk averse people I know. I don’t mean politically conservative, although most surgeons and pilots tend to identify with that end of the political spectrum. I mean conservative in the sense of resistance to change, reliance on personal responsibility over group responsibility, and acceptance of adverse consequences when a decision goes sideways.

Those who are forced to deal with risk on a daily basis develop ways to both mitigate and tolerate it. Doing the same thing, the same way, every time is one strategy. Checklists and pre-flight or preoperative planning are others. Some of these behaviors and strategies are based on controlled studies of the best, least risky ways to accomplish the task. Others are heuristic – we are trained to do it the way our mentors and teachers did and we continue that way because it works. This creates an extreme aversion to change. Change is bad. Change is an invitation to disaster. The only thing worse is change you don’t control.

This aversion to risk carries over into life outside the operating room or cockpit. Even when engaged in what some might consider ‘risky’ sports or recreation, that risk tends to be personal in nature and controlled.

Surgeons are intimately acquainted with risk and its consequences. The ability to tolerate risk and to mitigate it to the extent possible is the mark of a good surgeon. Most of us do this automatically. The calculus of risk versus benefit when assessing a patient is ongoing and often is only a minimally conscious process. Most surgeons are not routinely involved with high-risk patients or procedures. Many consciously avoid them. Trauma and emergency surgery does not offer that opportunity. You take what you get and do your best in the immediate situation.

 

 

Rules of Surgery

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Rules of Surgery

 

  1. Operations are for other people. This is self-evident to most surgeons. Contrary to popular perception, most surgeons are not ‘knife happy’. We are intimately familiar with the Law of Unintended Consequences and do not recommend surgery lightly. It follows then, that we would be extremely reluctant to have surgery ourselves. We know all the bad and unexpected stuff that can happen. Plus, we’re all control freaks and anesthesia and surgery represent an intolerable loss of control.
  2. The patient is the one with the problem. Leave your bad day, the fight with your spouse, the unpaid bills and all that personal crap at the door to the operating room. It has no place in surgery. Your sole focus should be on the patient and their operation.
  3. Don’t mess around. Get in, do the job, get out, in the most expeditious manner possible. That doesn’t mean hurry. Speed in surgery doesn’t come from moving fast, it comes from moving efficiently. The surgeon who doesn’t waste motion, doesn’t do things that are of no use, is the fast, safe surgeon that you want doing the operation.
  4. Training never stops. As my friend, the late Troy Brinkerhoff, used to say, “Every day is a school day.” You never stop learning new techniques, new ways to look at a problem, new approaches that improve your efficiency. Plus, it’s so damn interesting, how could you not continue to train?
  5. Wishful thinking is for losers. Just because you want something to be so, doesn’t make it true. Never let your expectations or desires color your judgment.
  6. Be familiar with all specialties. You may be a general surgeon, but you should know enough medicine to be a passable Internist. You should know what the gynecologist does and how in general to do a hysterectomy or oophorectomy as well as how to do a proper pelvic exam. You need to know the basics of Orthopedics, Urology and Thoracic surgery because there will come a time at 0-Dark:30 when you are all alone in the operating room and will need those skills.
  7. Learn to see what cannot be seen and to touch what cannot be felt. This sounds a bit mystical, but is about developing intuitive knowledge and instinct. In other words, learn when to trust your gut. More often than not, it will show you the way.
  8. If the operation is difficult, you’re doing something wrong. It may be that you’ve made the wrong incision or chosen the wrong procedure. Maybe you picked the wrong patient (didn’t account for all the potential risks before operating). Figure out what’s wrong and the operation will become easy.
  9. All bleeding stops eventually. It’s your job to make that happen while the patient is still alive.
  10. God watches out for fools, drunks, and young surgeons. Sometimes it is better to be lucky than good.

Wedding Day

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Wedding Day, Take Two

 

I’ve been reminiscing lately about my life. Writing a memoir by definition dredges up memories. Sometimes the strongest memories are those we don’t drag up from the depths by effort of will, but those that surface on their own in response to a situation or a chance remark. Such was the memory of advice that was given to me on my wedding day by my Chief of Surgery.

I had not thought of J.R. in many years. He died too young (only three years older than I am right now) back in 2002. He was one of only a few people in my life who profoundly affected the course I would take. His teaching shaped the surgeon and thus the person that I would become. To me, he idealized the virtues I have sought to cultivate as a surgeon. He was not perfect, and with the perspective of years and age I am able to see many of his flaws in a more mature light. Nevertheless, his mentorship and insistence on my best effort under his instruction made me the surgeon I am today.

It began with a chance remark from a scrub tech with whom I often work. He asked if Michele, my wife and for the past twenty years, my first assistant in the OR, would be scrubbing the case we had later that day.

I told him she would and he said, “Good. Cases go a lot smoother when she scrubs.”

I already knew that and agreed with him.

He went on, “I don’t know how she does it. She helps you here, she works as a Nurse Practitioner in her own office and she does your books, too, doesn’t she? She sure is a busy woman.”

Those remarks made me think about all of the roles she plays in my life. She is a passionate and multitalented woman and over the years we have forged a strong, intimate partnership in both our personal and professional lives.

That realization brought back the memory of the wedding day conversation with J.R. that I had all but forgotten. It was at our second wedding, the big traditional affair at the Navy Chapel – mess dress uniforms, white dress, swords, the whole nine yards. We were at the reception afterward. The traditional dances and toasts were done and Michele and I were mingling with our guests, moving from table to table spending time with our friends and family.

We had become separated for a few minutes as Michele stopped to talk with some friends from college. I found J.R sitting by himself. He shook my hand and congratulated me as I sat down next to him, welcoming the chance to get off of sore feet.

“Dr. Glass and I had a running bet about how long it would take you to wise up and ask that girl to marry you,” he said. “Glass won.”

“Did he take the short or the long bet,” I asked.

“Long. The whole department knew you two were an item at least a month before the August Hail and Farwell,” he said, referring to the first departmental function Michele and I had attended as a couple.

He watched Michele laughing with her girlfriends for a moment, and then said, “I hope you understand what an asset she is for you.”

That surprised me. I hadn’t heard things put quite that way. “I do, sir,” I said.

He gave me that scornful look that I knew so well from M&M conference. “No you don’t. No one who’s developed your skills by your age could.” He looked across the room to where his own wife was talking with some of the junior residents. “I know I didn’t. Treat her well, encourage her, and someday you will.”

Thirty years later I am beginning to understand, and it keeps me looking forward to the next thirty years